Tracheostomy bleeding

Background

Tracheostomy Sizes

(1) Thyroid cartilage (2) Cricothyroid ligament (3) Cricoid cartilage (4) Trachea (A) Cricothyrotomy site (B) Tracheotomy site

Tracheotomy in situ
1 – Vocal folds
2 – Thyroid cartilage
3 – Cricoid cartilage
4 – Tracheal rings
5 – Balloon cuff

Shiley™ trach tube

• Average size:
  • Adult: 5-10mm
  • Peds: 2.5-6.5mm

Tracheostomy vs laryngectomy

It is important to differentiate between tracheostomy vs laryngectomy

• If laryngectomy:
  • The stoma is the only way to ventilate the patient.
  • Patient cannot be orally intubated

Clinical Features

• Minor bleeds within first few days usually due to:
  • Lack of hemostasis
  • Tube suction and manipulation
  • Tracking of blood from nearby surgical site

Risk Factors

• Infection
• Corticosteroids
• Diabetes

Differential Diagnosis

Tracheostomy complications

• Tracheostomy obstruction
• Tracheostomy dislodgement
• Tracheostomy infection
• Tracheostomy bleeding

Evaluation

• Large bleed is tracheoinnominate fistula until proven otherwise

Management

• Local Bleeding
  • Use silver nitrate if bleeding source is identified
• Brisk Bleeding
  • Tracheoinnominate artery fistula (TIF) until proven otherwise
    • Most patients present within first 3wk after tracheostomy
    • May be preceded by hours to days with small-volume "sentinel bleed"
    • Very high mortality rate
    • Delegate team member to obtain surgical assistance, especially with massive bleed
    • Treatment:
      1. Hyperinflate the cuff (85% successful), up to 50 cc to tamponade bleeding
      2. If above fails, withdraw tube while placing pressure against anterior trachea
         • ETT from above (as long as there is no laryngectomy)
         • Apply digital pressure of innominate artery against the manubrium from inside tracheostomy tract
         • Go to the OR with finger tamponade innominate artery
      3. If above fails, place a cuffed ET tube to prevent pulmonary aspiration of blood
      4. Correct coagulopathies and administer blood products as needed
    • Requires emergent OR exploration and definitive management

Disposition

• Emergent OR for TIF
• Most minor bleeds do not require admission and observation if controlled in ED
• Consult with primary surgeon for new tracheostomies

References

• Allan JS, Wright CD. Tracheo-innominate fistula: diagnosis and management. Chest Surg Clin NA. 2003;13(2):331-41.